2000 Award for Excellence in Program Innovation

The Archstone Foundation Award for Excellence in Program Innovation was created in conjunction with the Gerontological Health Section of the American Public Health Association, and was established to recognize the best practice models in Gerontology and Geriatrics. Emphasis is given to those innovative programs that have effectively linked academic theory with applied practice in the field of public health and aging.

This year we are pleased to announce the winners of the Archstone Foundation Award for Excellence in Program Innovation as follows:

Co-winners of the top honor

Experience Corps, John Hopkins University, School of Hygiene and Public Health, Baltimore, Maryland.

This program represents a highly innovative, best practice model in aging and health, which effectively links academic theory with public health practice in the field of aging.

The Experience Corps is a new model of senior service designed to simultaneously create new, generative and productive roles for older adults meeting unmet needs of public elementary schools, and to provide a social model for health promotion for older adults that could be taken to a national scale. It is designed to be attractive to the full diversity of community-dwelling older adults, with roles for people of all backgrounds. The model was designed to place older adult volunteers in public elementary schools, in roles selected by the principal as the greatest needs for improving academic outcomes. The program was designed in the mid-1990's by Dr. Linda Fried at the Johns Hopkins Center on Aging and Health, and Marc Freedman at Civic Ventures, Inc. Its goal is to incorporate into one program exposure to a number of risk factors that research has shown to be beneficial to healthy aging. Its design was based on research evidence showing that;

Remaining physically active, even at low to moderate levels, improves well-being and protects against major chronic diseases of aging, depression, disability and mortality. Despite this evidence, interventions for older adults that solely target modification of health habits, such as exercise programs, thus far attract only a subset of older adults, and only a fraction of these are compliant over the long run.

Participating in structured, productive social activities, such as volunteering, decreases risk of disability and mortality and improves psychological health; notably, the number of hours per week in which older adults perform volunteer activities is associated, in linear fashion up to a threshold, with decreased disability risk.

Generativity (or leaving one's legacy), per Erick and Joan Erikson, is essential to successful psychological development in late life. It has been pointed out that there is significant structural lag in our society, such that, while people are retiring younger, generative opportunities are lacking for the large proportion of older adults that seek them.

Social networks and support are associated with decreased mortality in older adults, at the same time that they are likely to diminish as people age.

Regular exposure to complex environments is associated with enhanced cognition and with corresponding increases in brain connections in the hippocampus. However, interventions to date that are designed for cognitive stimulation have impact but low generalizability and retention.

The designers of the Experience Corps hypothesized that a program that could attract large numbers of older adults based on meeting their personal needs to "give back" and to be socially engaged, but was simultaneously designed to be health promoting, might have greater long-term compliance and health benefit than, for example, interventions to date to increase physical and cognitive activity. This research evidence was merged with current knowledge about the most effective senior service programs into the design of the Experience Corps.

The Experience Corps seeks to create new types of generative roles for older adults that will be attractive to a large proportion of the older population, decrease structural lag, increase social, cognitive and physical activity and confer health benefits for participants, while harnessing the largely untapped human capital of an aging society to help meet important social needs. The essential elements of the Experience Corps design creatively incorporate both maximizing health outcomes for adults 60 years of age and older, and the impact of the program on the schools. These elements include;

Roles that are meaningful for older adults, selected by the principal to make an important difference in children's outcomes. These roles were designed and standardized, and training developed, by Experience Corps investigators, and include literacy and math support, library programs, violence prevention programs, enrichment activities, and public health program such as personal hygiene instruction and an asthma management club for children with asthma, run by older adults with asthma.

Volunteer 15 or more hours per week, to maximize outcomes.

Training and infrastructure support provided by program.

Experience Corps volunteers work in teams of 7-10. A critical mass of volunteers, as determined by the principal, are placed in each school; the number ranges from 15-60 per school.

Diversity of older adults: all backgrounds of individuals can participate.

Learning: program flexibility permits identification of additional needs and development of new Experience Corps programs.

Reimbursement for expenses: volunteers receive $150/month to cover program expenses.

Leadership: volunteers evolve into leadership roles to make the program self-sustaining.

Evaluation: by volunteers, through journaling, and by the program developers. Since 1996, this program has been a Demonstration Project funded by the Corporation for National Service, with programs in 10 U.S. cities.

Programs in several other cities have been funded through foundations. Dr. Fried and colleagues have implemented a pilot for a randomized trial of the Experience Corps in Baltimore, beginning fall 1999 in 6 schools, which is jointly sponsored by the John Hopkins Center on Aging and Health and a community organization, the Greater Homewood Community Corporation. It is funded by the State of Maryland, the State Department of Education, the Baltimore City School Board, the Baltimore City Commission on Aging and Retirement Education, and the Corporation for National Service. This latter pilot in Baltimore has, thus far, refined screening and recruitment procedures, demonstrated an ability to recruit over 200 volunteers 60 years of age and older in only 4 months, and demonstrated that schools and older adults are willing to be randomized in order to demonstrate the effectiveness of the program. They have also developed standardized modules for training older adults in different intervention roles, and manuals of operation, which are able to be scaled up to a national program.

Across all of these programs, adults 52-91 years of age have participated. They have been almost one-third male and 67-89% African American, with 24-35% married. Educational levels vary, with 32-80% having less than a high school education. In the previous year, 44-65% had not volunteered. The volunteers average 2.2 chronic conditions. In the national demonstration, early data suggest improvements in social, psychological, cognitive and physical function for the older adults, and deep satisfaction with the ability to "make a difference" through the Experience Corps. Principals, teachers, older adults and children are highly enthusiastic about the program. Teachers describe improvements in literacy by at-risk elementary age children as a function of the Experience Corps. The Baltimore program has had no dropouts among the volunteers with consistently high satisfaction with the program.

This program has been designed for replication. The creators of the Experience Corps are now seeking to scale up to a randomized trial of 60 schools and 6000 older adults in order to demonstrate benefits for both target groups and what is entailed in taking this program to a national scale.

Assistive Equipment Demonstration Project, The Gerontology Institute at the University of Massachusetts Boston and the Executive Office of Elder Affairs.

The Gerontology Institute at the University of Massachusetts Boston (UMB) and the Executive Office of Elder Affairs (EOEA) collaborated on a three year demonstration project, with evaluation research funded by the Robert Wood Johnson Foundation. This project disseminated low-cost assistive equipment through case managers to elderly clients of a publicly-funded home care program, with the aim of increasing elders' independence in personal care and household management. Although it has been documented that assistive equipment can be highly beneficial to functionality disabled older people, such equipment is typically underutilized by elders and has not been a routine service of the home care programs within Massachusetts, which serve over 30,000 frail elders. An informational manual and website were developed based on the demonstration findings, and the manual is being distributed to home care programs statewide.

Collaborations and Funding

The demonstration was carried out through two state-funded home care programs representing comparable client populations that permitted a quasi-experimental evaluation design. The project involved collaborations with a rehabilitation hospital that provided case manager training and a professional survey research center that conducted interviews with project participants. While the Robert Wood Johnson Foundation provided funding for research activities, the assistive devices (allocated at $150 per client) were purchased with existing state home care funds, and the interventions were carried out with existing case management resources.

Population Served

In Massachusetts, state-funded home care clients must be low income, have limited informal supports, and demonstrate significant deficits in ADL and/or IADL, functioning. Nearly 200 clients received assistive equipment through the demonstration. Project participants were typically female (87%), white (97%), and single (85%), with ages ranging from 61 to 101 (median, 81). Over half the participants had at least two ADL deficits and nearly all had at least four IADL deficits. Typically, participants received 3 or 4 formal services. Nearly all used homemaker services, with other commonly used services including home-delivered meals, home health aides, transportation, skilled nursing, and personal care attendants.

Based on self-report interviews, half the clients reported that preparing meals was difficult. Although the majority of clients had one or more bathing devices prior to the demonstration, a third reported bathing to be difficult, and a quarter could not bathe at all without personal assistance. A third of the clients reported difficulty dressing or engaging in leisure activities.

Description of Services

Because case managers' cooperation was critical to achieving the projects' ultimate objective- increasing elders' use of low cost assistive equipment, the project included two complementary services, case management training and client equipment. The training and client screening materials were provided by occupational therapists from a rehabilitation hospital. A client screening tool was developed to assist case managers in identifying clients who might benefit from assistive equipment and in recommending equipment based on clients' functional limitations. During regularly scheduled home visits, case managers spoke with clients to decide on the assistive equipment items they wanted. The home care programs each developed their own procedures for ordering, delivering, and tracking the equipment. Case managers followed up the delivery of equipment with visits or phone calls to determine whether clients were using and satisfied with their equipment, and whether they needed demonstrations or other equipment.

Research Design to Evaluate Outcomes

The project employed a pretest/post-test experimental design to evaluate the impact of the intervention. Equipment delivery was delayed six months for one of the home care programs (the control group) to allow comparisons between clients who had received equipment and those who had not. Clients participated in in-home interviews at baseline, and were re-interviewed after six months. The control group completed a third interview six months after they received equipment. Baseline interviews addressed clients' perceived difficulty with tasks associated with meal preparation, bathing, dressing, and expressive activities. Clients were also asked about their use of and desire for assistive equipment. The second round of interviewing was similar, with additional questions for the experimental group that addressed specific items participants had received as part of the project, as well as clients' experiences around selecting and receiving equipment. In addition to the interviews, client background and services information was collected from client records at baseline and at the time of follow-up interviews.

Outcomes

Thirty seven case managers from the two home care programs received training and distributed equipment to, on average, 5 clients. As a result of the project, clients received an average of four assistive devices at an average cost of $76 per client. Nearly half the distributed items addressed meal preparation, followed by bathing or toileting, mobility, and dressing equipment. Most clients (88%) expressed satisfaction with their equipment and, according to case managers, 71% of the clients were using their equipment regularly after two weeks. There were also indications that clients' capacity to perform tasks addressed by specific items was increased. For example, clients who received and reported using adaptive can or jar openers reported less difficulty opening cans or jars. Moreover, case managers reported increased awareness of the range and benefits of assistive equipment and were more likely to consider assistive equipment as a service option.

Policy Implications

The Massachusetts state-funded home care program reaches over 30,000 community-residing elders, most of whom do not have ready access to professional occupational therapy services. The project demonstrated the potential for case managers, with modest training, to recommend and encourage the use of low-cost assistive equipment for many frail elders experiencing difficulties with self-care activities. The overall cost of equipment was minimal and could be absorbed within existing home care budgets. At the same time, implementation and procedural challenges were identified. Based on the experiences of the demonstration, the research team developed resource materials that are being distributed to home care programs throughout Massachusetts. These materials along with additional resources are also available on the Gerontology Institute's website at the University of Massachusetts Boston. It is expected that these materials will assist home care programs state-wide as they consider incorporating assistive devices within their range of service options.

We received 32 nominations this year, all of which truly excelled in program innovation. It is our hope that these model programs can be replicated in an effort to enhance services to the aging population in the United States.